INTRODUCTION

Regarding the unquestionable reality of Brazil's demographic and epidemiological changes that began in the last century, the aging population is facing difficulties in the health and social security systems. It is well known that, although the aging process is not necessarily related to diseases and disabilities (^{Miranda et al., 2016}), it is perceived the challenges of the multiple health, psychosocial and economic issues that can be generated by the growth of an aging population (^{Canedo et al., 2018}; ^{Knapik et al., 2019})

To understand this problem, countries worldwide have sought to understand how this aging process occurs, its implications, and what actions should be taken from public policies to maintain older adults' integration into society. So, it is important to assure the importance of guaranteeing the older adults not only a greater survival but also a good Quality of Life (QoL), guaranteeing to these individuals public policies aimed at their physical, psychological and social well-being (^{Andrade et al., 2018}; ^{Rosa et al., 2016}).

According to the World Health Organization, quality of life can be defined as "an individual's perception of their position in life in the context of the culture and value systems in which they live and concerning their goals, expectations, standards, and concerns". QoL includes a number of aspects, such as functional capacity, socio-economic level, emotional state, social interaction, intellectual activity, self-care, family support, health status, cultural, ethics and religion, lifestyle, satisfaction with the job and/or daily activities, and the environment in which one lives (^{de Oliveira et al., 2019}; ^{Noronha et al., 2016}; ^{Uchmanowicz & Gobbens, 2015}).

Among the factors that influence or compose the perception of quality of life, health is an important factor. Regarding the forms of health evaluation, the self-reported perception has been widely used in population studies because it indicates a better relationship with the actual health status of the individual (^{de Oliveira et al., 2019}; ^{Uchmanowicz & Gobbens, 2015}). Health perception is an indicator used in health surveys that, although subjective, provides an effective, fast, and cost-effective measure on the health of population groups (^{MacLeod et al., 2016}; ^{Silva et al., 2012}; ^{Tkatch et al., 2017}).

Thus, understanding the factors that influence older adults' health perception and quality of life indicates an important strategy to reduce the difficulties faced by this population. The expansion of knowledge of these factors may help in adopting preventive strategies and implementing public policies specifically aimed at mitigating the deleterious effects of certain determinants on the health status of the older adult population (^{Dao-Tran et al., 2018}; ^{Scarabottolo et al., 2019}).

As a result of the geographic, population, cultural and socio-economic differences, more studies are needed to understand the factors associated with the perception of quality of life and health of older adults in different Brazil regions. Considering the relevance of the topic, this study has as main goal to analyze factors associated with the negative perception of health and quality of life of older adults of a city in the countryside of the northeast of Brazil.

METHODS

It is a descriptive study with a cross-sectional design. The descriptive studies aim to determine health conditions according to the time, place, and characteristics of individuals through data collected for the research development (^{Cavalcanti et al., 2018}). Cross-sectional studies measure factor and effect at a particular historical moment, and they are useful for assessing the health needs of the population by providing indicators of trends and personal and demographic characteristics (^{Tolonen et al., 2006}).

RESULTS

Sample characterization is described in Table 1, being the majority female, prevailing young, and retired older adults.

Regarding socio-economic variables, it was identified that 96% of the older adults included in this study are retired, and 88.8% of the sample are financially responsible for the family. The study also showed that the majority of the participants (93.7%) were classified in an extract for the middle / low class, even though most of them believe that living with relatives has a positive impact on their life.

Regarding the variables health satisfaction and perception of QOL, it was demonstrated that most of the older adults included in this study presented positive responses, which means they are satisfied with their health, as well as with a good perception of quality of life.

Finally, regarding the level of physical activity, 54.5% of the older adults were considered active. However, a large portion of this sample had poor physical fitness scores for upper limb flexibility, lower limb flexibility, and agility.

The association's results in the univariate and multivariate analysis between negative perception of health and independent variables are presented in table 2. In the univariate model, only the upper and lower limb flexibility variables were significantly associated with the Negative Health Perception outcome (p = 0.007 ep = 0.002, respectively).

Regarding the variable upper limbs, the flexibility of older adults, two and a half times greater odds of association between poor flexibility and negative health perception were verified, compared to the older adults who presented good flexibility. There was a similarity in the results of lower limbs flexibility; older adults with poor flexibility had almost three times greater chances of association with the negative health perception. The variables gender and financially responsible were included in the multivariate model, besides variables with significant values (p ≤ 0.20).

In the multivariate model, the variables poor flexibility of the upper limbs and lower limbs remained significant for the association, showing both almost two and a half times more chances of negative health perception (p = 0.007 and p = 0.002, respectively). The other variables were not significantly associated.

Table 3 shows the association's significance values between negative perception of quality of life and the independent variables in the univariate and multivariate models.

Concerning the univariate model, there were associations with negative perception of quality of life, the variable financially responsible, and poor flexibility of lower limbs (p = 0.022 and p = 0.001, respectively). In the study, the older adults who were not financially responsible for their family showed a 67% lower chance of a negative perception of quality of life compared to the older adults responsible for their family financially. Poor lower limb flexibility showed almost three times greater chances of negative perception of quality of life. Variables gender, age, family relationship, physical activity level, socio-economic status, upper limb flexibility, and agility were not significant; therefore, they were not included in the multivariate analysis.

The multivariate analysis observed an association between the negative perception of quality of life and the variables financially responsible and lower limbs flexibility (p = 0.040 and p = 0.002, respectively). The older adults who were not responsible for the family had a 64% less chance of negative perception of quality of life, and older adults with poor flexibility in the multivariate analysis had almost three times higher odds of negative perception of quality of life.

DISCUSSION

The main objective of the present study was to analyze the associated factors with negative health perception and quality of life in a sample of older adults registered in the SIAB database of the municipality of Cedro de São João - SE.

In this study, the older adults included in the sample had a slightly higher percentage of health satisfaction and a positive perception of quality of life, 53.1% and 53.6%, respectively. This result is also seen in other studies in Brazil regarding health satisfaction, with variations between 50.4% and 80.9% (^{Borim & Neri, 2012}; ^{Confortin et al., 2015}) and a positive perception of quality of life, varying between 46.8% and 84.3% (^{Guimarães et al., 2011}).

According to ^{Sodergren et al. (Södergren et al., 2008}), demographic and socio-economic factors are related to lifestyle and directly associated with health perception of older adults, being able to determine a positive or negative perception. Studies have shown that older adults with a higher level of physical activity have greater associations with higher levels of positive perception of quality of life (^{Guimarães et al., 2011}). In addition, the study by ^{Souza et al. (Souza et al., 2014}), in consonance with other studies (^{Lee et al., 2012}; ^{Lu et al., 2017}; ^{Wang et al., 2015}; ^{Wang & Zhao, 2012}), reported that family interactions that characterize a better family functionality (organization, cohesion and family support), interfere positively in the quality of life of the older adults. Thus, the health satisfaction and positive perception of quality of life described in the present study can be explained as most of the included elderly individuals showed higher levels of physical activity and had a positive perception of living with the family.

Based on studies found in the literature, even though it was inferred that the previously described variables positively influenced the health satisfaction and perception of quality of life, other variables may have influenced the result of the percentage of older adults who reported health dissatisfaction and negative perception of quality of life, which was quite high. Thus, the associations made between the independent variables, negative health satisfaction and negative perception of quality of life, with the dependent variables, sociodemographic, physical fitness, and physical activity levels, could demonstrate their relation.

Regarding the negative health satisfaction, statistically significant associations were demonstrated only with the variables upper limb flexibility and lower limb flexibility, which means older adults with worse levels of flexibility of upper and lower limbs were more likely to be dissatisfied with their health condition.

A plausible explanation for this association may be related to the fact that, according to the American College of Sports Medicine (^{Chodzko-Zajko et al., 2009}), flexibility is one of the components responsible for the functional capacity of the individual. The International Classification of Functioning, Disability, and Health (^{WHO, 2018}) defines functionality as the result of the interaction between the dysfunction presented by the individual, the ability to participate in their activities and socialization, and environmental factors that can influence positively or negatively on performance and participation in these activities. Thus, in agreement with other studies, it is understood that the older adults who present difficulties to perform functional activities have a significant association with negative health perception (^{Alves et al., 2008}; ^{Boring et al., 2017}; ^{Tkatch et al., 2017})

Despite the considerations made by authors that only physical conditions would not be enough to determine the health perception (^{Tkatch et al., 2017}), this study understands the complexity of the variable flexibility and its relation with an extremely important condition for the older adults health, which is the functional capacity. Thus, the study becomes valid as it considers not only the variable flexibility but the relations it presents and its representation in the life of older adults.

Regarding the negative perception of quality of life, statistically significant associations were found with the variables being financially responsible and lower limbs flexibility. The association verified with the financial responsibility of the older adults showed a protective factor, which means older adults who were not financially responsible for the home environment presented lower chances of having a negative perception of quality of life, both in the univariate and multivariate analysis.

In regions of the low-income population in Brazil, it is common for older adults to be the main financially responsible family member. Their income usually comes from retirement income divided by the number of people who live or depend on it to survive. This can negatively influence the older adults health, as a high portion of their income should be earmarked for the purchase of medicines, food, and the satisfaction of their basic needs (^{Chen & Chen, 2017}; ^{Gerino et al., 2015}; ^{Muszalik et al., 2011}; ^{Silva, 2016}).

Studies have shown an association between socio-economic conditions and quality of life of older adults. The study done by ^{Paiva et al. (2016}), which included 3430 older adults from the southern triangle of Minas Gerais, revealed that the absence of income is associated with a negative perception of quality of life, and the authors explained that the low scores of the environment domain from WHOQOL-bref questionnaire could have occurred because most of the older adults have income between 1 and 3 minimum wages.

Furthermore, the study done by ^{Alexandre et al. (2009}) points out that older adults who have income above 5 minimum wages are associated with better results in the environmental domain of the WHOQOL-bref questionnaire. The present study found that the majority of the older adults included in the sample were retired, middle / lower class, and financially responsible in their families.

Regarding poor flexibility of the lower limbs, the association verified a risk ratio, which means the worse the level of flexibility, the greater the chance of the older adults presenting a negative perception of quality of life. This finding can also be explained by the relationship between flexibility and functional capacity of older adults. ^{Guimarães and Farinatti (2005}) mention that reduced lower limb flexibility is associated with falls in the older adults, mainly due to the loss of mobility of the hip, knee, ankle, and spine joints, with consequent changes in gait pattern and difficulties in performing daily tasks, such as using public transport or walking.

Finally, there was no association between physical activity level and negative health satisfaction, and negative perception of quality of life. However, it is worth mentioning that almost 55% of the older adults reported being active / very active in relation to the practice of physical activity but presented poor results in the variables of physical fitness analyzed. This result can be explained by the fact that the instrument used to assess the level of physical activity includes several domains of physical activity, enabling the older adults to reach the recommendations of physical activity, but not necessarily performing activities that enable the development of flexibility and agility skills, which were evaluated objectively. In addition, the physical activity level assessment instrument collects data from self-report, which the answers depend on the memory and veracity of the information offered by the participants, which may influence the result.

CONCLUSION

In general, socio-economic factors and physical fitness presented significant associations to negative health satisfaction and negative perception of quality of life. The variable flexibility was associated with negative health satisfaction, both upper and lower limb flexibility, and the negative perception of quality of life, only with lower limbs, demonstrating the importance of this motor capacity and its relation with the functional capacity of the older adults. Also, being financially responsible was associated with a negative perception of quality of life, demonstrating the influence of the socio-economic conditions of the older adults included in the study on their quality of life.

Researches on this theme are important and enable the knowledge, monitoring, and comparison of results to guide the decision-making regarding the formulation of health policies. Thus, it is important to create public policies aiming at the health and well-being of older adults, including constant monitoring of the conditions that can affect this population regarding the diverse contexts that they are submitted.